COCs oar ea shaks | Q1) Case 1: A56 yo man, a carpenter, noticed that he suddenly experienced numbness and tingling in his left arm, accompanied by loss of movement of same arm. Later that same day, he continued his construction b erienced similar symptoms in the same hand, again lasting about S minutes, At this time, which of the following most likely is his iiagnosis? . Multiple Sclerosis 46% 46% . Amyotrophic Lateral Sclerosis . Simple Focal Seizure @D. Transient Ischemi . Cerebrovascular Accident moowmp aLSO ORRISIHRSUBK Case 1 Q2) Two days later, he decided to finish his project. A few hours later, he collapsed on his bench. His co-worker immediately went to his side but he was poorly responsive. The co-worker frantically called 911. At the scene, the paramedic reported that the patient had to make an effort to speak but the content made sense. Also that he had weakness on his right side. His deficits in speech were most likely due to damage of which areas of the brain? Postcentral gyrus, Brodmann’s area 3,1,2 Precentral gyrus, Brodmann area 4 Inferior gyrus Frontal lobe, Brodmann’s areas 44, 45 Parietal lobe, Brodmann’s area 22, 40 Superior gyrus of Temporal lobe, Brodmann’s area 22, 39, 40 Precentral gyrus, Brodmann’s area 3,1, 2 Frontal lobe, Brodmann’s areas 22, 45 2u2 Se g O™MoOODpPNeuroanatomic Correlates -Where is the lesion? CNS Patterns of Weakness High Brain StemeRga-ig¢ exo |__|] Q3) CT scan revealed no hemorrhage in this patient. Two and half hrs after onset of his symptoms today, pharmacotherapy was commenced. i ations, what is the primary mechanism of action of the drug that most likely was administered? A. Converts circulating plasminogen to plasmin, which then binds to fibrin in clot B. Binds to fibrin in clot and converts entrapped plasminogen to plasmin, initiating local fibrinolysis C. Interference with thromboxane A2 through COX1 inhibition preventing platelet aggregation D. Increases the inhibitory action of antithrombin III on clotting factors Xila, Xla, IXa and Xa and thrombin E. It inhibits vitamin K reductase which decreases the activity of factors II, VII, IX, XGeos oe res sma || | Q3) CT scan revealed no hemorrhage in this patient. Two and half hrs after onset of his symptoms today, pharmacotherapy was commenced. i ations, what is the primary mechanism of action of the drug that most likely was administered? A. Converts circulating plasminogen to plasmin, which then binds to fibrin in clot B. Binds to fibrin in clot and converts entrapped © plasminogen to plasmin, initiating local fibrinolysis C._ Interference with thromboxane A2 through COX1 inhibition preventing platelet aggregation D. Increases the inhibitory action of antithrombin III on clotting factors Xila, Xla, Xa and Xa and thrombin E. It inhibits vitamin K reductase which decreases the activity of factors II, VII, IX, X 5% 5% DUZLSO seusOT Oe OO Coe ett a ROR CLC (Grasp, sucking reflexes Abulia, paratonic sgidity, gait apraxia Dominant hemisphere: aphasia, motor and sensory deficit (he amy fee > foot), may be complete hemiplegia if intemal capsuleinv6l 7 homonymous hemianopia Non-dominant hemisphere: neglect, anosognosia, motor and sensory deficit Gace, am > leg > foot), homonymous hemianopia XY Homonymous hemianopia; alexa without agraphia (dominant hemisphere): brat artery) Visual hallucinations, visual perseverations (calcarine cortex); sensoryloss, choreoathetosis, spontancouspain thalamus); II nerve palsy, paresis of vertical eve movement, motor deficit (cerebral peduncle, midbrain) Pure motor hemiparesis (classic lacunar syndromes) Pure sensory deficit Penetrating vessels _ Pure sensory-motor deficit ©\ Hemiparesis, homotateral ataxia Dysarthria chumsy hand Cranial nerve palsies Crossed sensory deficits Diptopia, dizziness, nausea, vomiting, dysarthria, dysphagia, hiccup Limb and gait ataxia Motor deficit Coma Bilateral signs suggest asilarartery disease Progressive of stuttering onset of MCA syndrome, occasionally ACA. Intemal carotid artery arome as well if insufficient collateral flowSOSROBI SUBKS | Q4) Suppose this patient had several contraindications to thrombolytic therapy and had died after hospital admission. Which of the follo cell types would most likely be seen on microscopic examination of hi fected area of the brain 2 weeks after death? . Red neurons and reactive astrocytes Swollen neurons Red neurons and foamy macrophages . Proliferating oligodendrocytes Neutrophils Reactive astrocytes and foamy macrophages 7moOOm>PTC a eM =a) Transient Ischemic Attack (TIA) and TIAs or a history of TIA are never to be ignored and must be fully evaluated, like stroke. Note in TIA there is risk of permanent tissue injury. + Tissue-based definition of TIA o a transient episode of neurologic dysfunction caused by focal brain, spinalBRIS SUBKS | Q5) A 13-year-old boy (son of Case 1) presents to a mental health clinic with his parents. His history is significant for stealing video games from a store and several suspensions from school for fighting, threatening teachers, and bringing a weapon to school. The boy’s mother is also concerned because he has been failing classes and has run away twice in the last month, because of being punished for suspensions. When asked about his behavior, the patient does not express remorse and states that he “does what he wants.” These behaviors have occurred over the last year. This pattern of behavior is most consistent with which diagnosis? « Oppositional defiant disorder s Conduct disorder c. Attention deficit hyperactivity disorder o. Reactive attachment disorder « Learning disorder 22504OCs eer ea shanks | Q5) A 13-year-old boy (son of Case 1) presents to a mental health clinic with his parents. His history is significant for stealing video games from a store and several suspensions from school for fighting, threatening teachers, and bringing a weapon to school. The boy’s mother is also concerned because he has been failing classes and has run away twice in the last month, because of being punished for suspensions. When asked about his behavior, the patient does not express remorse and states that he “does what he wants.” These behaviors have occurred over the last year. This pattern of behavior is most consistent with which diagnosis? « Oppositional defiant disorder s Conduct disorder c. Attention deficit hyperactivity disorder ». Reactive attachment disorder e Learning disorder ple 2504 fe.SOs OSes a shaks | ‘Beeecl Q 6) A55-year-old woman (wife of carpenter in case 1) complains of persistent fatigue and sadness over the past 3 months. This began since losing her job during the COVID pandemic. She also reports feeling worried during this time. The patient describes her fatigue as “having little or no energy to do anything. When asked what she enjoys doing, she reports that she has not engage her usual outdoor/soc 'S, and she feels hopeless about her life. The ient did not endorse sui joughts but repored difficulty with concentration and falling asleep. She indicated that she felt this way before, approximately two years ago, which lasted 6 months. Which of the following is the most likely diagnosis A. Post-traumatic Stress disorder j B. Bereavement se C. Adjustment disorder : D. E. 108 . Persistent depressive disorder . Major depressive disorder o% omExplanation slide Major depressive disorder (MDD) + The patient reported symptoms of persistent fatigue, sadness, worry, anhedonia, hopelessness, difficulty with concentration, and sleep concerns. These symptoms have lasted for approximately 3 months. Although they follow a difficult event (i.e., losing her job), her symptoms are over and above what is expected for adjustment disorder and meet criteria for MDD. Because the symptoms have not occurred for at least two years and meet criteria for MDD, this would not be Persistent Depressive Disorder. Although the patient reports worry, her symptoms are more consistent with those of depression. There is no suggestion of hypomanic episodes, so Bipolar II disorder would not be considered.Q7) One year later: The mother unable to still unable find job started her husband’s carpentry trade. However a piece of wood accidently fell on her head from the shelf. Her son immediately rushed to her side. She said that she was feeling okay but later collapsed. At the ER, a fracture of the skull was noted. She later succumbed. The image below was taken at her autopsy. Which of his vessels most likely was damaged due to his injury? . Middle meningeal artery . Dural bridging veins . Middle cerebral artery . Internal carotid artery Superior sagittal sinus mooopQ7) One year later: The mother unable to still unable find job started her husband’s carpentry trade. However a piece of wood accidently fell on her head from the shelf. Her son immediately rushed to her side. She said that she was feeling okay but later collapsed. At the ER, a fracture of the skull was noted. She later succumbed. The image below was taken at her autopsy. Which of his vessels most likely was damaged due to his injury? . Middle meningeal artery . Dural bridging veins . Middle cerebral artery . Internal carotid artery Superior sagittal sinus st ole ols A. B. c D. E.Q8) Before his death, which of the following images were most likely similar those taken on this patient? D) f 1 f A) B) 24250 ° E) moOoOm> moou>Geosnega Q8) Before his death, which of the following images were most likely similar those taken on this patient? D) ae DULUSo .. -~ Ef ° E) moOoOm> moou>What are the types of Intracranial Hemorrhage? Differentiate clinically. + All share some classic clinical features. Common presenting symptoms + headache, nausea, vomiting, confusion, somnolence, or seizure — However there is a wide clinical spectrum: > patients may be alert and conversant, or moribund SAH — anacute, “sudden” onset “thunderciap” headache. May also have loss of consciousness (LOC), vomiting, neck stiffness, or EDH — Fractures of temporal lobe with disruption of middle meningeal artery — brief LOC after a blow to the head, followed by a lucid period. Subdural hematomas — bridging veins — Since the bleeding Is venous and low-pressure, the hematoma can grow fairly slowly and the presentation can be delayed by days to weeks Intracerebral hemorrhage — Bleeding within the parenchyma of the brain. — Can be secondary to numerous etiologies including uncontrolled hypertension, ruptured saccular aneurysms, vascular malformations or traumatic injury. ~ Typically - headache, nausea, vomiting and depressed mental state. May also be comatose or severely obtunded. hitps://ivww.saem.org/edem/education/online-education/m4-curriculum/group-m4-neurology/intracranial-hemorthageExplain the difference in CT findings: * Epidural hematomas + Subdural hematomas are convex toward the are concave toward the brain (biconvex, lenticular shaped) brain and unlimited by — They are restricted by suture lines (crescent shaped) suture lines. — Rarely, a subdural hematoma appears lens shaped (i.e., more like a \ epidural hematoma). https://www.medscape.com/answers/ 113° 120/which-ct-findin gnostic-of-subdural-hematoma-sdh#: text=Subdural%20hematomas%20ar -ave%20toward,subdural%20hematomas%20are%20usually%20unilateral,SOCSNOSCe STK | Q10) Further examination of the patient’s brain at autopsy also revealed several 1-3 cm round-oval nodules with perifocal edema found in the both cerebral hemispheres. In addition, a hemorrhagic lesion in the brainstem was visualized (see the attached image). Which of the following conditions is the most likely cause of the described hemorrhages? . Coagulation defect . Arteriovenous malformation . Subfalcine herniation . Transtentorial herniation Tonsillar herniation mooopQ10) Further examination of the patient’s brain at autopsy also revealed several 1-3 cm round-oval nodules with perifocal edema found in the both cerebral hemispheres. In addition, a hemorrhagic lesion in the brainstem was visualized (see the attached image). Which of the following conditions is the most likely cause of the described hemorrhages? 36% A. Coagulation defect B. Arteriovenous malformation C. Subfalcine herniation 10% @D. Transtentorial herniation | 0% E. Tonsillar herniation | Z4256 1986SROgaie Q13) The wife of patient from Case 1 scenario is prescribed citalopram. “The 56-year-old woman complains of persistent fatigue and sadness over the past 3 months, since losing her husband. She also reports feeling worried during this time. The patient describes her fatigue as “having litle or no energy to do anything.” When asked what she enjoys doing, she reports that she has not engaged in her usual outdoor/social activities, and she feels hopeless about her life. The patient did not endorse suicidal thoughts but reported difficulty with concentration and falling asleep. She indicated that she felt this way before, approximately two years ago, which lasted 6 months.” However she is fearful of taking her medication because of the possible side-effects. Which of the following would you tell her is the most frequent side effect associated with her treatment? A. Seizures . Drowsiness . Dry mouth . Tremor Nausea moooQ 14) A19 year old man has a sore throat followed a day later by sudden onset of a severe headache. Significant physical examination: nuchal rigidity and mild pharyngitis. His skin showed petechial hemorrhages. His temperature was 38.8° C, pulse 98/min, respirations 26/min, and BP 95/45 mm Hg. The figure below showed the representative gross appearance of the surface of his brain. Which of the following infectious organisms was most likely to have produced his disease? Cryptococcus neoformans Mycobacterium tuberculosis . Neisseria meningitidis . Poliovirus Toxoplasma gondii moom>eRoaie axvl oer | Q15) At the clinic, his doctor observes that the patient suddenly stops speaking and moving, and stares forward for a few seconds. This is followed by rhythmic lip smacking and eye blinking for several seconds. His entire body then stiffens, followed by rhythmic jerking movements, mostly of his extremities, also for several seconds. He is incontinent of urine. Following the seizure, he remains confused and disoriented for several minutes. Which of the following is the best description for this seizure type? Tonic-clonic seizure Absence seizure Complex focal seizure ‘Simple focal seizure Simple focal seizure secondarily generalized Complex focal seizure secondarily generalized 7™M™OODPOCsNoGrensuaky | Q15) At the clinic, his doctor observes that the patient suddenly stops speaking and moving, and stares forward for a few seconds. This is followed by rhythmic lip smacking and eye blinking for several seconds. His entire body then stiffens, followed by rhythmic jerking movements, mostly of his extremities, also for several seconds. He is incontinent of urine. Following the seizure, he remains confused and disoriented for several minutes. Which of the following is the best description for this seizure type? Complex focal seizure oa 21% Simple focal seizure Dew Simple focal seizure secondarily generalized % 7moop> Complex focal seizure secondarily generalized Tonic-clonic seizure be ao tre on Absence seizure ies | ? ZY 504 .BRIS SUBKD | Q16) The patient experienced repeated seizures. As part of the treatment, phenytoin was given. This drug exhibits dose-dependent elim kinetics. Which of the following pharmacokinetic parameters of this drug most likely decreases by increasing the dose? . Half-life . Clearance . Time to reach steady state . Volume of distribution . Oral bioavailability moowpQ18) A 30 year old man was poorly compliant with his anti-epileptic medication. During his last seizure, he fell and hit his head and developed acoma. His condition continues to deteriorate. His vital signs are now BP: 152/92 mm Hg. Pulse 56/min. After checking the other vital signs, his doctor noted that Cushing's Triad is occurring. Which of the following most likely was observed in this patient to justify this comment? Respiratory rate increased Respiratory rate decreased No change in vitals Temperature increased O2 sat reduced moompp>Q20) A 42 -year-old woman is brought to the ER with an extremely severe headache. This is the first occurrence. PMH: Ankylosing spondylitis. PMH : Nil. Social History: Occasional alcohol. Fundoscopy: Spontaneous retinal pulsations not seen. Which of the following is the most likely diagnosis? . Migraine headache . Brain tumor . Cluster headache . Trigeminal neuralgia . Panic attack ™mooop oR Sentinel bleedGEeosnee smuaxe | ~ | Q20) A 42 -year-old woman is brought to the ER with an extremely severe headache. This is the first occurrence. PMH: Ankylosing spondylitis. PMH : Nil. Social History: Occasional alcohol. Fundoscopy: Spontaneous retinal pulsations not seen. Which of the following is the most likely diagnosis? 100% . Migraine headache . Brain tumor . Cluster headache . Trigeminal neuralgia . Panic attack ee ote ome 7 Sentinel bleed A BC DD EF F ™mooop